DiarrheaA messy subject
CaseA 1 year old girl is brought to clinic with 3 days ofwatery brown diarrhea, vomiting, and irritability. Onexam the chi...
“More than 70 per cent of almost 11million child deaths every year areattributable to six causes: diarrhoea,malaria, neona...
Deaths per year from diarrheal illness • United States: 6,000 • Developing world: 1.5 to 2 million  (children < 5 years ol...
Classification of diarrheaWGO Practice Guideline – Acute Diarrhea March 2008
Acute diarrhea• Acute diarrhea is usually a self-  limited infectious illness• Usually viral (Norwalk) or bacterial• Vomit...
Acute diarrhea: clinical priorities• Look at the stool    - rice water stool: cholera    - bloody stool: dysentery• Assess...
Exam: nutritional and volume status
Kwashiorkor:                    Marasmus:     lack of protein        protein + calorie malnutrition  www.cs.stedwards.edu ...
Exam: volume status• Adults and Children   • Tachycardia, postural hypotension   • Jugular venous distension   • Mucous me...
WGO Practice Guideline – Acute Diarrhea March 2008
If the gut works, use it
Oral rehydration saves livesWGO Practice Guideline – Acute Diarrhea March 2008
Oral rehydration solution (ORS)         Rice-based ORS is superiorto glucose-based ORS in patients with choleraWGO Practic...
Rx of mild/moderate dehydrationWGO Practice Guideline – Acute Diarrhea March 2008
Rx of severe dehydrationWGO Practice Guideline – Acute Diarrhea March 2008
Acute diarrhea Rx - children• Admit to hospital if malnourished, severely    dehydrated, age < 1 year, recent measles• ORS...
Acute diarrhea Rx - adults• ORS or IV fluids (RL, NS) if severely dehydrated• Bismuth or loperamide (contraindicated if th...
Dysentery• Bloody stools• Shigella, enterohemorrhagic  E coli (EHEC), other bacteria  – often with fever• Enteric fever (s...
Dysentery: Antibiotics• Antibiotics recommended for:   • Salmonella typhi, ameoba   • Extremes of age   • Immunocompromise...
Antimicrobials• Cholera   • Adults: doxycycline 300 mg once, or tetracycline 500 mg     daily x 3 days   • Children: azith...
Persistent diarrhea - children• Among infants in developing  countries, 20% of acute  diarrheal illnesses become  chronic•...
Persistent diarrhea - adults• Consider HIV• Campylobacter ileitis: chronic  diarrhea, RLQ tenderness,  signs of inflammati...
Lab tests• Stool for ova and parasites    • Especially in severe or persistent diarrhea• Fecal leukocytes    • Suggests co...
CaseA 1 year old girl is brought to clinic with 3 days ofwatery brown diarrhea, vomiting, and irritability. Onexam the chi...
ResourcesWGO Practice Guideline – Acute Diarrhea March 2008
Upcoming SlideShare
Loading in …5
×

Microsoft PowerPoint - Topazian - Diarrhea 2009.ppt [Read-Only]

4,971 views

Published on

1 Comment
1 Like
Statistics
Notes
No Downloads
Views
Total views
4,971
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
167
Comments
1
Likes
1
Embeds 0
No embeds

No notes for slide

Microsoft PowerPoint - Topazian - Diarrhea 2009.ppt [Read-Only]

  1. 1. DiarrheaA messy subject
  2. 2. CaseA 1 year old girl is brought to clinic with 3 days ofwatery brown diarrhea, vomiting, and irritability. Onexam the child is lethargic, afebrile, with sunkeneyes and a weak pulse of 140/minute. Which of thefollowing is the best management plan?A) Check CBC and stool tests for pathogensB) Prescribe oral rehydration solutionC) Prescribe oral antibioticsD) Begin IV fluids and hospitalize
  3. 3. “More than 70 per cent of almost 11million child deaths every year areattributable to six causes: diarrhoea,malaria, neonatal infection, pneumonia,preterm delivery, or lack of oxygen atbirth.” - UNICEF
  4. 4. Deaths per year from diarrheal illness • United States: 6,000 • Developing world: 1.5 to 2 million (children < 5 years old) World Gastroenterology Organization (WGO) Practice Guideline Acute Diarrhea (March 2008)
  5. 5. Classification of diarrheaWGO Practice Guideline – Acute Diarrhea March 2008
  6. 6. Acute diarrhea• Acute diarrhea is usually a self- limited infectious illness• Usually viral (Norwalk) or bacterial• Vomiting: - Viral - Ingestion of a pre-formed toxin• Profuse watery diarrhea: - Viral - Cholera - Giardia - Ingestion of a pre-formed toxin http://bepast.org/docs/photos/cholera/rice-water %2520stool.jpg• Risk factors for death: - Extremes of age, malnutrition, immunocompromise
  7. 7. Acute diarrhea: clinical priorities• Look at the stool - rice water stool: cholera - bloody stool: dysentery• Assess severity - signs of dehydration, malnutrition http://spirochetesunwound.blogspot.com - abdominal exam - body temperature• O + P exam for moderate/severe illness• Hgb if pt looks anemic http://biology.unm.edu/ccouncil/Biology_203/Images
  8. 8. Exam: nutritional and volume status
  9. 9. Kwashiorkor: Marasmus: lack of protein protein + calorie malnutrition www.cs.stedwards.edu www.glahaiti.orgMalnutrition is a major risk factor for diarrhea mortality
  10. 10. Exam: volume status• Adults and Children • Tachycardia, postural hypotension • Jugular venous distension • Mucous membranes• Children • Urine output, dry mouth/eyes • Sunken fontanelle • Skin turgor • Irritable or lethargic, drinking poorly
  11. 11. WGO Practice Guideline – Acute Diarrhea March 2008
  12. 12. If the gut works, use it
  13. 13. Oral rehydration saves livesWGO Practice Guideline – Acute Diarrhea March 2008
  14. 14. Oral rehydration solution (ORS) Rice-based ORS is superiorto glucose-based ORS in patients with choleraWGO Practice Guideline – Acute Diarrhea March 2008
  15. 15. Rx of mild/moderate dehydrationWGO Practice Guideline – Acute Diarrhea March 2008
  16. 16. Rx of severe dehydrationWGO Practice Guideline – Acute Diarrhea March 2008
  17. 17. Acute diarrhea Rx - children• Admit to hospital if malnourished, severely dehydrated, age < 1 year, recent measles• ORS if dehydrated; IV fluids (RL, NS) if severely dehydrated; rehydrate over 3 to 6 hours• Re-feed as soon as rehydration is accomplished• Zinc 20 mg daily x 14 days• Antibiotics not usually indicated• Give antibx for: • Dysentery • Suspicion of cholera or enteric fever • Giardiasis or amebiasis
  18. 18. Acute diarrhea Rx - adults• ORS or IV fluids (RL, NS) if severely dehydrated• Bismuth or loperamide (contraindicated if there is fever or bloody stool)• Antibiotics not usually indicated• Give antibx for: • Dysentery (some cases) • Suspicion of cholera or enteric fever • Giardiasis or amebiasis
  19. 19. Dysentery• Bloody stools• Shigella, enterohemorrhagic E coli (EHEC), other bacteria – often with fever• Enteric fever (salmonella typhi)• Amebiasis – no fever (unless in liver)• Less likely causes: ischemic colitis or inflammatory bowel disease• Infectious dysentery is usually a self-limited disease that does not require antibiotic therapy
  20. 20. Dysentery: Antibiotics• Antibiotics recommended for: • Salmonella typhi, ameoba • Extremes of age • Immunocompromised or malnourished patients • Toxic patients, suspicion of sepsis• Antibiotic Rx may precipitate hemolytic-uremic syndrome in children, especially in library.thinkquest.org/26260/pg1.html industrialized countries
  21. 21. Antimicrobials• Cholera • Adults: doxycycline 300 mg once, or tetracycline 500 mg daily x 3 days • Children: azithromycin, TMP/SMX, furazolidone, norfloxacin• Shigellosis • Adults: ciprofloxacin 500 BID x 2 days, or azithromycin or ceftriaxone • Children: ciprofloxacin 15 mg/kg BID x 2 days, or azithromycin, or ceftriaxone 50-100 mg/kg daily i.m. x 2-5 days • Resistance is common• Giardia • Metronidazole, tinidazole, nitazoxanide, or paromomycin• Ameoba • Metronidazole followed by iodoquinol or paromomycin
  22. 22. Persistent diarrhea - children• Among infants in developing countries, 20% of acute diarrheal illnesses become chronic• Enteropathogenic E coli (EPEC), Giardia• Vicious cycle of diarrhea and malabsorption leading to death• Consider HIV• Rx is largely nutritional: • Iso-osmolar carbohydrate porridge, via feeding tube if needed • MVI and zinc • Antibiotics
  23. 23. Persistent diarrhea - adults• Consider HIV• Campylobacter ileitis: chronic diarrhea, RLQ tenderness, signs of inflammation• TB enteritis: doughy abdomen• Parasites: Giardia, ameoba, cryptosporidium, isospora belli, cyclospora• Wasting, or fat in stool? Consider sprue, chronic pancreatitis• Inflammatory bowel disease or malignancy http://scanned.files.wordpress.com/ 2007/10/aidspatient2.jpg
  24. 24. Lab tests• Stool for ova and parasites • Especially in severe or persistent diarrhea• Fecal leukocytes • Suggests colitis, invasive organism• CBC • Won’t alter acute Rx, unless there are signs of severe anemia• Stool culture • Usually not available or required• Stool Sudan stain (fecal fat) • In chronic diarrhea with weight loss• X-Ray: if concern for toxic megacolon
  25. 25. CaseA 1 year old girl is brought to clinic with 3 days ofwatery brown diarrhea, vomiting, and irritability. Onexam the child is lethargic, afebrile, with sunkeneyes and a weak pulse of 140/minute. Which of thefollowing is the best management plan?A) Check CBC and stool tests for pathogensB) Prescribe oral rehydration solutionC) Prescribe oral antibioticsD) Begin IV fluids and hospitalize
  26. 26. ResourcesWGO Practice Guideline – Acute Diarrhea March 2008

×